What is Oral Herpes?
Oral herpes labialis, also known as a cold sore, is caused by the virus Herpes simplex type 1 (HSV-1). After the first initial infection, the HSV-1 virus becomes dormant. It can recur anytime afterwards as an infectious lesion. Rarely, herpes simplex type 2 (HSV-2), commonly referred to as genital herpes, may cause primary infection of the oral cavity. Recurrence of oral HSV-2 disease is rare.
It has been found that 80% of the population are asymptomatic carriers of the virus, while 20-40% of people have experienced cold sores at some time. The infection is more prevalent in lower socioeconomic groups, with an overall global growth in the last twenty years.
What are the Risk Factors?
Transmission can occur by direct contact with saliva and blood, whether the infection is asymptomatic or symptomatic. The risk of transmission is highest for 1-4 days from the onset of symptoms, but the duration of infectiousness may last up to 12 days. Factors that may trigger a recurrence of oral herpes simplex include immunosuppression (eg corticosteroids), upper respiratory tract infections, fatigue, emotional stress, physical trauma, exposure to sun (ultraviolet light), trauma and menstruation.
How is the Manifestation?
Infection with herpes simplex virus (HSV) can cause pain and blistering within the mouth (gingivostomatitis or recurrent oral ulceration), or on or around the lips (cold sores or herpes labialis).
Primary infection: Most often occurs in infancy or childhood. It may or may not be symptomatic. Gingivostomatitis is the most common presentation in young children. It presents with vesicles and ulcers on the tongue, lips, gums, buccal mucosa and hard and soft palates. Pain, inability to swallow, drooling and dehydration are common. There may be associated fever, cervical lymphadenopathy, halitosis, lethargy, loss of appetite and irritability. Pharyngitis is a more common presentation in adolescents, with lesions in the throat associated with viral symptoms similar to those of glandular fever. Herpetic whitlow may occasionally occur via spread to the fingers.
Recurrent infection: Cold sore lesions are the most common form of recurrent disease. They tend to occur in the same location, be unilateral and recur two or three times a year on average. Prodromal symptoms may occur 6-24 hours before the appearance of a lesion and include tingling, pain and/or itching in the perioral area. Cold sores are usually seen on the lips and extend to the skin around the mouth. Other areas on the face, chin, or nose are sometimes involved. Lesions begin as erythematous areas that swell into papules. These become vesicles, which then collapse into ulcers. This takes 1-3 days. The ulcers crust over and the skin returns to normal within about 2 weeks. Oral mucosal lesions are rare and not generally associated with fever. They are usually restricted to small clusters of microvesicles that rupture to leave punctate ulcers, typically on the gums near the roof of the mouth. Immunocompromised people may develop chronic ulcers, often on the tongue.
What is the Management?
Cold sores or gingivostomatitis is usually mild and self-limiting, and so can be managed symptomatically. Reassure that lesions will heal without scarring. A soft diet may be needed: drinking lots of water should also be encouraged to prevent dehydration. Give advice to reduce risk of transmission: Avoid touching the lesions. Wash hands with soap and water immediately after touching lesions, such as after applying medication. Topical medications should be dabbed on rather than rubbed in to minimise trauma. Don’t share topical medications or other items that come into contact with a lesion area, eg lipstick or lip gloss, with others. Avoid kissing until the lesions have completely healed. Avoid oral sex until all lesions have completely healed. There is a risk of transmission to the eye if contact lenses become contaminated. Children with cold sores do not need to be excluded from nurseries and schools.
Advise to seek medical advice if the person’s condition deteriorates (eg the lesion spreads, a new lesions develops after the initial outbreak, persistent fever, inability to eat) or no improvement is seen after 7-10 days.
What is the Drug Treatment?
Paracetamol and ibuprofen are effective in relieving pain and fever. Local analgesic for gingivostomatitis – benzydamine mouthwash or spray (age 5 and over). Chlorhexidine mouthwash for gingivostomatitis (aged 7 and over). Choline salicylate gel for pain control of cold sores (contra-indicated under the age of 16 due to Reye’s syndrome). Lidocaine gel for pain control of cold sores (licensed for use in patients aged 12 and over). Topical antiviral agents: Aciclovir 5% can be used from the age of 3 months. Penciclovir 1% cream should be used from the age of 12. The benefits of topical antivirals are small and cold sores usually resolve within 7-10 days even without treatment. Topical antivirals do not prevent future episodes of cold sores alone but one study found that a combination of aciclovir and hydrocortisone showed some preventative activity. Treatment needs to be initiated at the onset of symptoms before vesicles appear. Topical antivirals need to be applied frequently for a minimum of 4-5 days.
Oral antiviral agents: For immunocompetent individuals, oral antivirals are not routinely indicated for the treatment of cold sores but may be indicated in severe episodes only. Seek specialist advice for people who are immunocompromised (including people with HIV). Aciclovir is active against herpes viruses but does not eradicate them. It can be used as systemic and topical treatment of herpes simplex infections of the mucous membranes and is used orally for severe herpetic stomatitis. Valaciclovir is an ester of aciclovir. It is licensed for herpes simplex infections of the skin and mucous membranes.
Laser treatment is also an option for severe breakouts. Low-intensity laser has been used in a patient with severe herpes simplex virus type 1 (HSV-1) infection of the lower lip with rapid relief of pain after one application.
What are some Complications?
Dehydration can occur during infection, especially in children. Recurrent lesions at the same site may occasionally cause atrophy and scarring. Secondary bacterial infection, including impetigo, can occur. Eczema herpeticum can complicate atopic eczema. Bell’s palsy is possibly a complication of herpes simplex infection. Rare complications include dissemination, herpes encephalitis, meningitis, corneal dendritic ulcers (ocular herpes simplex) and erythema multiforme.
What is the Prognosis?
Oral herpes simplex is usually a self-limiting disease. Lesions (whether due to primary infection or recurrent disease) usually heal within 1-3 weeks, without scarring.
Is there any Prevention?
Sunscreen may be useful for people who have recurrences triggered by sunlight. There is no evidence available to support the use of topical antivirals for the prevention of cold sores. Prophylactic oral antivirals are not generally recommended for immunocompetent individuals. There is only limited evidence that prophylactic oral aciclovir or valaciclovir reduces the frequency and severity of attacks of cold sores. Oral antivirals do have a role in prophylaxis for people with frequent or severe episodes, or for immunocompromised individuals (specialist advice should be sought). Laser phototherapy may help to reduce the frequency of attacks in recurrent herpes labialis.
Aphthous Mouth Ulcers
What are aphthous mouth ulcers?
Aphthous mouth ulcers, also known as canker sores, are painful lesions that can recur from time to time. The ulcer(s) will usually go without treatment in 10-14 days. Mouthwashes and lozenges may ease the pain, and may help the ulcers to heal more quickly. Aphthous mouth ulcers are painful sores that can occur anywhere inside the mouth. They are the most common type of mouth ulcer. At least 1 in 5 people can develop aphthous mouth ulcers at some stage in their life, and women are affected more often than men.
There are three types of these ulcers. Minor aphthous ulcers are the most common (8 in 10 cases). They are small, round, or oval, and are less than 10 mm across. They look pale yellow, but the area around them may look swollen and red. Only one ulcer may develop, but up to five may appear at the same time. Each ulcer lasts 7-10 days, and then goes without leaving a scar. They are not usually very painful. Major aphthous ulcers occur in about 1 in 10 cases. They tend to be 10 mm or larger across. Usually only one or two appear at a time. Each ulcer lasts from two weeks to several months, but will heal leaving a scar. They can be very painful and eating may become difficult. Herpetiform ulcers occur in about 1 in 10 cases. These are tiny pinhead-sized ulcers, about 1-2 mm across. Multiple ulcers occur at the same time, but some may join together and form irregular shapes. Each ulcer lasts one week to two months. Despite the name, they have nothing to do with herpes or the herpes virus.
Aphthous ulcers usually first occur between the ages of 10 and 40. They then recur but there can be days, weeks, months, or years between each bout of ulcers. The ulcers tend to recur less often as you become older. In many cases, they eventually stop coming back. Some people feel a burning in part(s) of the mouth for a day or so before an ulcer appears.
What causes aphthous mouth ulcers?
The cause is not known. They are not infectious, and you cannot ‘catch’ aphthous mouth ulcers. In most cases, the ulcers develop for no apparent reason in people who are healthy. In some cases, the ulcers are related to other factors or diseases. These include injury – such as badly fitting dentures, a graze from a harsh toothbrush, changes in hormone levels, etc. Some women find that mouth ulcers occur just before their period. In some women, the ulcers only develop after the menopause. Some ex-smokers find they develop ulcers only after stopping smoking. A lack of iron, or a lack of certain vitamins (such as vitamin B12 and folic acid) may be a factor in some cases. Rarely, a food allergy may be the cause. Mouth ulcers run in some families. So, a genetic factor may play a part in some cases. Stress or anxiety is said to trigger aphthous mouth ulcers in some people. Some medications can cause mouth ulcers. Some medications that can cause them include nicorandil, anti-inflammatory drugs, and oral nicotine replacement therapy. Mouth ulcers are more common in people with Crohn’s disease, coeliac disease, HIV infection, and Behçet’s disease. But the ulcers may not be aphthous-type.
Tell your doctor if you have any other symptoms in addition to the mouth ulcers. Other important symptoms would include skin or genital ulcers or rheumatological (joint) pains and inflammation. Rarely, severe mouth ulcers can occur after taking a medicine you are allergic to. Sometimes a blood test or other investigations are advised if other causes of mouth ulcers are suspected.
What are the treatments for aphthous ulcers?
Treatment aims to ease the pain when ulcers occur, and to help them to heal as quickly as possible. There is no treatment that prevents aphthous mouth ulcers from recurring, and usually no treatment may be needed for resolution. The pain is often mild, particularly with the common ‘minor’ type of aphthous ulcer. Each bout of ulcers will go without treatment.
Patients with aphthous ulcers should avoid spicy foods, acidic fruit drinks, and very salty foods, which can make the pain and stinging worse. Use a straw to drink, to avoid the liquids touching ulcers in the front of the mouth. Use a very soft toothbrush. See a dentist if you have badly fitting dentures. If you suspect a medication is causing the ulcers, then a change may be possible. For example, if you are using oral nicotine replacement therapy (nicotine gum or lozenges), it may help to use a different type instead such as patches or nasal spray.
Some medicines may ease your symptoms from the mouth ulcers. Chlorhexidine mouthwash (brand name Corsodyl® or Chlorohex®) may reduce the pain. It may also help ulcers to heal more quickly. It also helps to prevent ulcers from becoming infected. Unfortunately, it does not reduce the number of new ulcers. Chlorhexidine mouthwash is usually used twice a day. It may stain teeth brown if you use it regularly. However, the stain is not usually permanent, and can be reduced by avoiding drinks that contain tannin (such as tea, coffee, or red wine), and by brushing teeth before use. Rinse your mouth well after you brush your teeth as some ingredients in toothpaste can inactivate chlorhexidine. Steroid lozenges (brand name Corlan® pellets or Betnesol® tablets) may also reduce the pain, and may help ulcers to heal more quickly. By using your tongue you can keep a lozenge in contact with an ulcer until the lozenge dissolves. A steroid lozenge works best the sooner it is started once an ulcer erupts. If used early, it may ‘nip it in the bud’, and prevent an ulcer from fully erupting. The usual dose is one lozenge, four times a day, until the ulcer goes. In children, use for no more than five days at a time. A barrier paste or powder such as carmellose sodium (brand name Orabase® and Orahesive®) can be applied to the ulcer to protect it and reduce pain. A painkilling oral rinse, gel, or mouth spray may help to ease pain. Examples include benzydamine spray (brand name Difflam®), or choline salicylate gel (brand name Bonjela®). Bonjela® should not be used in children under the age of 16 due to a potential risk of Reye’s syndrome if it is overused. This is the same reason why aspirin cannot be used in children too. Note: Bonjela teething gel® no longer contains choline salicylate and has been reformulated with lidocaine, a local anaesthetic (to cause temporary numbing).The effect of painkilling medicines is unfortunately short-lived.
You can buy all the treatments listed above from pharmacies without a prescription. Other treatments may be tried if the above do not help or where the pain and ulceration are severe. Examples include, a course of steroid tablets, strong steroid mouthwashes, colchicine, tetracycline or doxycycline mouthwashes, and some immunosuppressant drugs.
When should I see a doctor?
Aphthous mouth ulcers can be painful and are often a nuisance, but are not serious. Occasionally a mouth ulcer can become secondarily infected with bacteria. In this case, you may notice increased pain or redness, or you may be feeling unwell with fever. Secondary bacterial infections are not common but may need antibiotic treatment. Remember, not all mouth ulcers are aphthous ulcers. Other types of ulcer can occur in the mouth and mouth ulcers can be a sign of an underlying illness or disease.
Oral cancer can sometimes start as an unusual mouth ulcer that does not heal. You should see a doctor or dentist if you have a mouth ulcer that has lasted more than 2-3 weeks without sign of healing, or is different in any way. This is especially important if you are a smoker. Your medical doctor or dentist may refer you urgently to the outpatient clinic to see an ear nose and throat (ENT) specialist or an oral (mouth) surgeon. A small sample (biopsy) of the ulcer may be taken in clinic and examined, to exclude cancer.
Frequently Asked Questions about SpaDent Whitening
Is whitening safe?
Review of available studies indicates no evidence of harm to enamel based on our whitening procedure and gel application. Typically enamel problems are associated with acidic products. Our gel is virtually PH neutral (6.5PH) and has Xylitol which neutralizes the bacteria which causes plaque.
Will my teeth be sensitive after whitening?
A small percentage of people will have minor discomfort in their mouth and this normally dissipates within 10 minutes. For some people, the sensitivity can last a little bit longer, in which then we would recommend the use of a sensitivity toothpaste, like Sensodyne. If your gums are sensitive, this feeling will heal in a few days.
Does whitening harm caps, crows or veneers?
Our process will not harm any of these.
How long does whitening last?
Typical results vary based on a number of factors including genetics and lifestyle. While no two people are the same most people will want a single touch up session in approximately 6 months which can be booked with your next dental appointment.
How white will my teeth get?
A number of factors determine results including genetics and your starting shade. Almost all individuals depending on starting shade will see 2 to 8 shades after 2 sessions.
How often can I whiten?
The majority of people will need 2 initial sessions for first time whitening after which only a single touch up session is required.
How long before I can eat or drink after whitening?
For the first 24 hours we recommend avoiding coffee, tea, cola, red wine, berries, or any foods that have the propensity to stain. For the first hour drink only water.